ERIC eNews

Recent Childhood Continence Research

BJU Int. 2009 Jun;103(12):1706-12.
Failure of monotherapy in primary monosymptomatic enuresis: a combined desmopressin and propiverine treatment regimen improves efficacy outcomes.Alloussi SH, Mürtz G, Gitzhofer S, Eichel R, Lang C, Madersbacher H, Strugala G, Alloussi S.
OBJECTIVE: To evaluate, in a prospective study, the combination of the antimuscarinic propiverine and the antidiuretic hormone-agonist desmopressin in children and adolescents not responsive to previous monotherapy, as in primary monosymptomatic enuresis (PME), combined treatments are considered a second-line approach after the failure of monotherapy. PATIENTS AND METHODS: The study included 122 children and adolescents (mean age 10.8 years, range 5-21) with PME and so far unresponsive to single or multiple monotherapy. Propiverine (body weight <30 kg, 15 mg/day; >or=30 kg, 20 mg/day) and desmopressin (0.4 mg/night) were administered over 3 months, followed by successive structured withdrawal programmes for propiverine and desmopressin, depending on the amount of loss of urine at night before treatment. RESULTS: The re-evaluation of unresponsive patients, incorporating video-urodynamics, showed neurogenic detrusor overactivity, isolated detrusor sphincter dyssynergia and vesicorenal reflux in 12.3% (15/122) of patients, so far falsely treated as enuresis. In 107 of 122 patients the diagnosis of PME was confirmed. The primary efficacy outcome, continence at night, was achieved in 104 of 107 patients (97.2%). During the individual follow-up periods (3-12 months), 23 of 107 (21.5%) patients relapsed after withdrawal of both medications. Adverse events of moderate intensity were rare (3.7%). CONCLUSION: Re-evaluation of patients after monotherapy has failed is justified, because other entities can be discovered in patients so far treated unsuccessfully for enuresis. The combination of propiverine and desmopressin is highly effective in children with PME. Our results support the case for further optimizing the inaugurated treatment algorithm of PME for treatment duration, dose-titration and structured withdrawal programmes, thus possibly further decreasing relapse rates.

J Trop Pediatr. 2009 Jun;55(3):177-82.
Behaviour problems in young children in rural Bangladesh.Khan NZ, Ferdous S, Islam R, Sultana A, Durkin M, McConachie H.
OBJECTIVE: To determine the prevalence of child behaviour problems reported by parents in rural Bangladesh. METHODS: A total of 4,003 children aged 2-9 years were identified during a population-based survey of 2,231 households. A predetermined sample of 499 was selected, of which health professionals saw 453 (90.8%) for structured physical and neurological examination, standardized testing of cognition and adaptive behaviour and parent report of developmental history and behaviour problems. RESULTS: The prevalence of behaviour impairments was 14.6% (95% CI 11.4, 17.9). The majority involved somatic complaints, including nocturnal enuresis and pica. Problems such as aggression or restlessness were infrequently reported. Behaviour impairments were significantly associated with malnutrition (prevalence ratio 2.1, 95% CI 1.2, 3.6, p < 0.01) and cognitive, motor or seizure disabilities (prevalence ratio 1.8, 95% CI 1.1, 2.9, p < 0.05). CONCLUSIONS: The prevalence and nature of reported behaviour impairments in rural Bangladesh have implications for public health planning and delivery of health services.

Clin Gastroenterol Hepatol. 2009 Jun 30. [Epub ahead of print]
A randomized controlled trial of enemas in combination with oral laxative therapy for children with chronic constipation.
Bongers ME, van den Berg MM, Reitsma JB, Voskuijl WP, Benninga MA.
BACKGROUND & AIMS:: After 5 years of intensive oral laxative use, up to 30% of constipated children still have an unsuccessful outcome. Children refractory to oral laxatives might benefit from regular rectal evacuation by enemas. This randomized controlled trial compared the effects of additional treatment with rectal enemas (intervention) to conventional treatment alone (oral laxatives, control) in severely constipated children. METHODS:: In a tertiary hospital in the Netherlands, 100 children, aged 818 years, with functional constipation for at least 2 years were randomly assigned to intervention or control groups. The control group received education, behavioral strategies and oral laxatives. The intervention group was also given 3 rectal enemas/week, reduced by 1 enema/week every 3 months. Outcome measures were defecation and fecal incontinence frequency and overall success at 12, 26, 39 and 52 weeks. Overall success was defined as 3 or more defecations/week and less than 1 fecal incontinence episode/week, irrespective of laxative use. RESULTS:: Defecation frequency normalized in both groups, but was significantly higher in the intervention group compared with controls at 26 and 52 weeks (5.6 vs 3.9/week, p=0.02, and 5.3 vs 3.9/week, p=0.02, respectively). There were no significant differences between groups in reduction of fecal incontinence episodes (p=0.49) and overall success rates (p=0.67). After 1 year of treatment, the overall success rate was 47.1% in the intervention group vs 36.1% in the control group. CONCLUSIONS:: There is no additional effect of enemas compared with oral laxatives alone as maintenance therapy for severely constipated children.

J Pediatr Psychol. 2009 Jun;34(5):530-8.
Exploring the relationship between parental worry about their children’s health and usage of an internet intervention for pediatric encopresis.
Magee JC, Ritterband LM, Thorndike FP, Cox DJ, Borowitz SM.
OBJECTIVE: To investigate whether parental worry about their children’s health predicts usage of a pediatric Internet intervention for encopresis. METHODS: Thirty-nine families with a child diagnosed with encopresis completed a national clinical trial of an Internet-based intervention for encopresis (www.ucanpooptoo.com). Parents rated worry about their children’s health, encopresis severity, current parent treatment for depression, and parent comfort with the Internet. Usage indicators were collected while participants utilized the intervention. RESULTS: Regression analyses showed that parents who reported higher baseline levels of worry about their children’s health showed greater subsequent intervention use (beta =.52, p =.002), even after accounting for other plausible predictors. Exploratory analyses indicated that this effect may be stronger for families with younger children. CONCLUSIONS: Characteristics of individuals using Internet-based treatment programs, such as parental worry about their children’s health, can influence intervention usage, and should be considered by developers of Internet interventions.

J Pediatr Surg. 2009 Jun;44(6):1285-90; discussion 1290-1.
Transanal rectosigmoid resection for severe intractable idiopathic constipation.Levitt MA, Martin CA, Falcone RA Jr, Peña A.
INTRODUCTION: Idiopathic constipation is a source of significant morbidity in children. A subset of patients is refractory to medical therapy and requires surgical intervention. We present a novel surgical technique for the management of these patients. METHODS: We reviewed the records of 288 patients with severe idiopathic constipation and soiling. Patients who were refractory to medical management and had a megarectosigmoid underwent a transanal full-thickness rectosigmoid resection with a primary colo-anal anastomosis. RESULTS: Fifteen patients underwent a transanal rectosigmoid resection. The preoperative contrast enema demonstrated an enormously dilated rectosigmoid in 14. An average of 43 cm (range, 8-98 cm) of rectosigmoid was resected. Of 14 patients with more than 3 months of follow-up, the preoperative laxative dose was 68 mg of senna/d (range, 52-95 mg), which decreased to 8.6 mg postoperatively (P < .001). Nine patients are clean without soiling, 1 is more prone to diarrhea, but is clean. Two patients soil occasionally, but are noncompliant, and 2 were lost to follow-up. CONCLUSION: Transanal rectosigmoid resection for medically intractable idiopathic constipation resulted in a dramatic reduction or elimination in laxatives use while preserving continence. It is a useful alternative to surgical options such as other colonic resections, antegrade enemas, and stomas.

J Pediatr Surg. 2009 Jun;44(6):1268-72; discussion 1272. Improvement of quality of life in children with slow transit constipation after treatment with transcutaneous electrical stimulation. Clarke MC, Chase JW, Gibb S, Hutson JM, Southwell BR. BACKGROUND: Slow transit constipation (STC) causes intractable symptoms not responsive to medical treatment. Children have irregular bowel motions, colicky abdominal pain, and frequent soiling. Transcutaneous electrical stimulation using interferential current (interferential therapy [IFT]) is a novel treatment of STC. This study assessed quality of life (QOL) in STC children before and after IFT treatment. METHODS: Eligible STC children were randomized to receive either real or placebo IFT (12 sessions for 4 weeks). Questionnaires (Pediatric Quality of Life Inventory) were administered before and 6 weeks after treatment, with parallel parent and child self-report scales. Higher scores indicate better QOL. Holschneider and Templeton scores were also obtained. The QOL scores were compared using paired t tests. RESULTS: Thirty-three children (21 male), with a mean age of 11.8 years (range, 7.4-16.5 years), were recruited; 16 received real IFT. Child-perceived QOL was improved after real IFT compared with baseline (81.1 vs 72.9, P = .005) but not after placebo IFT (78.1 vs 74.9, P = .120). The Holschneider score improved after real IFT (10 vs 8, P = .015) but not after placebo IFT (9 vs 8, P = .112). Parentally perceived QOL was similar after real IFT (70.1 vs 70.3, P = .927) and placebo IFT (70.2 vs 69.8, P = .899). There were no differences in Templeton scores. CONCLUSION: Interferential therapy is a novel therapy for children with STC that improves their self-perceived QOL.

Child Care Health Dev. 2009 Jul;35(4):469-74. Relationship of sleep quality and quality of life in children with monosymptomatic enuresis. Ertan P, Yilmaz O, Caglayan M, Sogut A, Aslan S, Yuksel H. BACKGROUND: Health-related quality of life (QoL) in children with monosymptomatic nocturnal enuresis might be influenced by impaired quality of sleep. The aim of this study was to evaluate possible deteriorations in QoL and sleep quality and the association between these parameters in children with monosymptomatic nocturnal enuresis. METHODS: The study consisted of 44 children with monosymptomatic nocturnal enuresis and 27 healthy controls aged 6-15 years. KINDL QoL and Pittsburgh Sleep Quality Index (PSQI) were applied to all children. RESULTS: Mean total KINDL scores in enuresis and control groups were 65.1 +/- 11.0 vs. 67.4 +/- 13.7, respectively (P = 0.44). PSQI scores were not significantly different between the groups (P > 0.05l). In the enuresis group, age showed significant negative correlation with self-esteem domain of KINDL (r = -0.39, P = 0.01) and positive correlation with sleep duration sub-score of the PSQI (r = 0.37, P = 0.03). Duration of enuresis showed significantly negative correlation with total KINDL score and self-esteem domain (r = -0.32 and r = -0.39, P = 0.04 and P = 0.01, respectively). There was significant correlation between physical well-being sub-score of KINDL with daytime dysfunction and total scores of PSQI (r = -0.53, P = 0.001 and r = -0.41, P = 0.02, respectively). Daytime dysfunction sub-score of PSQI was significantly correlated with friends sub-score of KINDL (r = -0.33, P = 0.04). CONCLUSIONS: As age of the child and duration of enuresis increase, self-esteem domain of QoL worsens. Moreover, there is a significant correlation of physical well-being and friends domains of QoL score and total and daytime dysfunction scores of PSQI. These findings necessitate global evaluation of QoL and sleep quality in children with monosymptomatic nocturnal enuresis to increase efficacy of health care.

Curr Opin Urol. 2009 Jul;19(4):412-8. Nonneurogenic voiding disorders: what’s new? Glassberg KI, Combs AJ.
PURPOSE OF REVIEW: Increased interest in pediatric nonneurogenic voiding disorders (NNVDs), urodynamic testing and therapeutic options make this a timely topic for review. RECENT FINDINGS: The major themes covered this year included diagnosis of NNVD by symptomatology and relationship to subsequent urodynamic findings and treatment outcomes; effect of bladder volumes and overdistention, test position, catheter size, catheter in or out during voiding and sex on flow rate, flow pattern, voiding pressures, presence of overactivity and interpretation of findings on both urodynamic studies and uroflow testing; associations between bowel disorders (constipation and encopresis) and NNVD, associations between behavioral disorders and bowel disorders as reflected by treatment response and effect on behavior; efficacy studies on symptom-directed therapies in NNVD, comparison of different biofeedback programs for treating dysfunctional voiding, Botox injections for overactive bladder and an adult anticholinergic for overactive bladder that underwent testing in children; enuresis topics included anticholinergics for treating monosyptomatic enuresis refractory to desmopressin, prevalence of enuresis when screening large numbers of healthy school-age children and its association with certain family characteristics and other bowel and bladder complaints and an update on the association of fluctuation of vasopressin and nightly urine output and its role in patient selection for desmopressin therapy. SUMMARY: While some studies simply validated the past work of others, there were several that dispelled beliefs by demonstrating the inaccuracy of predicting voiding disorders on the basis of uroflow alone or the minimal effect of catheter and test position on urodynamic results; behavior disorders require special care but are not an impediment to successful treatment. Newer therapies, including Botox injections and new or broadened indications for existing anticholinergics, in treating the overactive bladder in children need closer scrutiny.

Pediatrics. 2009 Jul;124(1):e53-9. Nocturnal enuresis and overweight are associated with obstructive sleep apnea.Barone JG, Hanson C, DaJusta DG, Gioia K, England SJ, Schneider D.
OBJECTIVE: The objective of this study was to examine the relationship of obstructive sleep apnea (OSA), body weight (BMI percentage [BMI%]), and monosymptomatic nocturnal enuresis (MNE) in children. METHODS: A case-control study design was used. All children were 5 to 15 years of age; case patients were recruited from a comprehensive sleep disorders center (n = 149), and control subjects were recruited from a general pediatric practice in the same catchment area (n = 139). Case patients were subject to overnight polysomnograms and grouped into apnea severity categories (minimal, mild, moderate, or severe) on the basis of respiratory disturbance index and minimum arterial oxygen saturation levels. Data for all children included age; gender; height; weight; and history of MNE, snoring, diabetes, nasal allergies, and/or enlarged tonsils. BMI% was used to group children into weight categories as suggested by the Centers for Disease Control and Prevention (underweight, normal weight, at risk for overweight, and overweight). Two age groupings were created (5-10 years and 11-15 years). Descriptive statistics provided the prevalence of OSA, weight category, and MNE among case patients and control subjects. Cross-tabulations examined the relationship of severity of OSA with weight categories and MNE, stratified by age and gender. A series of logistic regression models explored the interrelationship of the grouping variables. RESULTS: A large majority (79.9%) of control subjects were at risk for overweight, and a large majority (80.0%) of children with MNE also had some degree of OSA. Logistic regression demonstrated that both MNE (odds ratio: 5.29) and overweight (odds ratio 4.16) were significantly associated with OSA but not with each other. CONCLUSIONS: Overweight and MNE are associated with OSA but not with each other. OSA should be considered in overweight children with MNE, especially when they display other symptoms of OSA or fail to respond to standard MNE treatment programs.

J Pediatr. 2009 Aug;155(2):239-44.e5. Nocturnal enuresis: a suggestive endophenotype marker for a subgroup of inattentive attention-deficit/hyperactivity disorder.Elia J, Takeda T, Deberardinis R, Burke J, Accardo J, Ambrosini PJ, Blum NJ, Brown LW, Lantieri F, Berrettini W, Devoto M, Hakonarson H.
OBJECTIVE: Attention-deficit/hyperactivity disorder (ADHD) and enuresis co-occur at a higher rate than expected; the cause for this is unclear. STUDY DESIGN: Diagnostic and demographic variables were compared in 344 children ages 6 to 12 years, with and without enuresis, recruited in an ADHD genetic study. Sleep variables were investigated in a subgroup of 44 enuretic children with age- and sex-matched nonenuretic controls. The association of enuresis with single nucleotide polymorphisms located in regions reported in linkage with enuresis was explored. RESULTS: The prevalence rate of nocturnal enuresis was 16.9% for the entire cohort. There were no differences in sex, age, socioeconomic status, intelligence quotient, medication treatment, or comorbidities. The enuresis group had a higher likelihood of inattentive symptoms than the nonenuretic group. Night wakings and ability of children to wake themselves in the morning were both significantly decreased in children with enuresis compared with control children in the Child Sleep Habits Questionnaire Night Wakings subscale. No significant association was found with 0chromosomal regions previously reported in linkage with enuresis. CONCLUSIONS: Deficits in arousal may contribute to both enuresis and inattentive ADHD. Nocturnal enuresis may be a useful clinical marker in identifying a subgroup of the inattentive phenotype in ADHD genetic studies.

J Paediatr Child Health. 2009 Jul-Aug;45(7-8):405-8. Efficacy of the bell and pad alarm therapy for nocturnal enuresis. Gim CS, Lillystone D, Caldwell PH.
AIM: (i) To determine the efficacy of bell and pad alarm therapy as an initial and relapse treatment for nocturnal enuresis; (ii) to explore risk factors for treatment failure; and (iii) to explore risk factors for relapse within 12 months of successful bell and pad alarm therapy. METHODS: A 22-item questionnaire was sent to 240 children who received bell and pad alarm therapy in a 6-year period via a community centre. The questionnaire recorded demographic characteristics of the child, length of the first bell and pad alarm therapy, outcome of initial treatment and relapse information. RESULTS: The initial response and relapse rates of bell and pad alarm therapy were 84 and 30%, respectively. Female gender, absence of diurnal symptoms and willingness to use alarm therapy were associated with better treatment outcomes. Treatment success was associated with shorter treatment length. The success rate of repeating alarm therapy after relapse was 78%, with an average length of treatment of 10 weeks. CONCLUSION: The bell and pad alarm therapy is an effective treatment for nocturnal enuresis both as initial therapy and after relapse. The association between patient characteristics and treatment response found in our study may help inform clinicians of likely treatment outcomes, and identify those who may need a different approach.

Eur J Pediatr Surg. 2009 Aug;19(4):220-3. Outcome of transanal endorectal pull-through in patients with Hirschsprung’s disease. Obermayr F, Szavay P, Beschorner R, Fuchs J.
INTRODUCTION: Various outcomes following transanal endorectal pull-through (TERPT) in patients with Hirschsprung’s disease (HD) have been reported. In this study, the postoperative course and functional outcome after TERPT in 25 patients with HD is evaluated. METHODS: Patient records of children who underwent TERPT for HD between 2002 and 2007 were reviewed retrospectively. Age at surgery, sex, associated malformations, length of follow-up, presence of colostomy, indication for laparotomy, length of the aganglionic segment, result of rectal examination under general anaesthesia 6 weeks after surgery, necessity of a dilatation program or reoperation were investigated. In addition, standardised interviews were performed to collect the following data: bowel movement per day, faecal continence in potty-trained children or in patients older than 3 years, incidence of diarrhoea or problems with micturition and the necessity for laxative therapy. RESULTS: Between 2002 and 2007, 25 patients underwent TERPT for HD. Median age at the time of surgery was 3.5 months. Median follow-up was 35 months. Calibration of the anus showed a normal age-related diameter of the anus in 12/20 children and a markedly reduced diameter in 8/20 children at 6 weeks postoperatively. Seven of the latter children underwent a dilatation program. A redo pull-through procedure was performed in 3 patients due to stenosis at the colo-anal anastomosis (n=1), a constricting muscle cuff (n=1) and a twisted pull-through (n=1). Two children developed enterocolitis. The median frequency of bowel movements was 3/day (1-5/day). Laxative treatment was required in only one patient (4.5%). None of the patients had diarrhoea. Nineteen children (86%) were potty-trained, being older than 3 years. Eighteen of them were continent (95%). One patient (5%) with trisomy 21 suffered from intermittent non-retentive faecal incontinence. None of the patients showed signs of neurogenic bladder dysfunction. CONCLUSION: The functional outcome in most patients after TERPT is satisfactory. We suggest that routine rectal digital examination and anal calibration under anaesthesia 6 weeks postoperatively might detect occult anodermal stenosis and allow early initiation of an anorectal dilatation program, which could decrease the incidence of enterocolitis, persistent constipation and the necessity for further surgical intervention. Copyright Georg Thieme Verlag KG Stuttgart . New York.

Ital J Pediatr. 2009 Aug 12;35(1):25. Functional constipation in children: does maternal personality matter? Farnam A, Rafeey M, Farhang S, Khodjastejafari S.
ABSTRACT: AIM: To identify personality dimensions of mothers with a constipated child and compare it with those mothers of children without defecation problems. METHODS: We compared mothers of 150 children with functional constipation to mothers of 150 children with no such a problem attending to pediatric hospital of Tabriz University of medical sciences. Personality dimensions were evaluated by NEO five factor inventory after excluding any psychiatric disorders by an interview. RESULTS: Mean age (SD) was 28.8(18.6) months in constipated children and 20.0(19.3) months in controls, 54.6% of constipated children and 56.7% of controls were male. Mean age (SD) was 30.9(7.1) years in mothers of children with functional constipation and 30.1(7.6) years in controls.Mothers of children with functional constipation scored lower in neuroticism and scored higher in extraversion, conscientiousness and agreeableness. Conscientiousness was the dominant dimension of personality in both groups. CONCLUSION: Our results suggest the maternal personality as a factor to directly influence toileting behavior of their children resulting in functional constipation.

J Urol. 2009 Aug;182(2):692-8. Quality of life and self-esteem for children with urinary urge incontinence and voiding postponement.Natale N, Kuhn S, Siemer S, Stöckle M, von Gontard A.
PURPOSE: Urge incontinence and voiding postponement are common subtypes of daytime wetting in children. We analyzed health related quality of life for children with urge incontinence and voiding postponement, and healthy controls at 2 centers. MATERIALS AND METHODS: We examined a total of 49 consecutive children 5 to 13 years old who presented with urge incontinence (22) or voiding postponement (27), and 32 controls matched for age and sex. Health related and overall quality of life were measured with generic questionnaires, and self-esteem was measured with the Piers-Harris questionnaire. RESULTS: Health related quality of life was significantly reduced in parent rating but not in child rating in the incontinent vs control group (total mean parent score 73 vs 78, child 76 vs 76). Children with voiding postponement have the lowest health related quality of life. Overall quality of life was significantly reduced in children with incontinence, while self-esteem did not differ. Children with externalizing disorders generally have the lowest health related and overall quality of life. CONCLUSIONS: Health related and overall quality of life are useful constructs, and are reduced in children with daytime incontinence by parental rating. In comparison, children rate their quality of life as being higher. Quality of life is lowest with externalizing behavioral disorders, as in children with voiding postponement. Due to comorbid behavioral disturbances, children with voiding postponement often need additional assessment, counseling and treatment.